Spatial Patterns of Hepatitis C Disease in Ghadezai Tehsil District

aphy & N r at og u e ra l G f D

o i s

a Journal of

r e

u r

s o

J Ali et al., J Geogr Nat Disast 2015, 5:3 ISSN: 2167-0587 Geography & Natural Disasters DOI: 10.4172/2167-0587.1000146

Research Article Open Access

Spatial Patterns of Hepatitis C Disease in Ghadezai Tehsil District Buner, Khyber Paktunkhwa, Pakistan Asad Ali1, Muhammad Shakeel2*, Shoaib Khalid1, Tanveer Ahmed1, Mubarra Noreen2 and Ali Rehan Munir1 1Department of Geography, Government College University Faisalabad-38000, Punjab, Pakistan 2Department of Geography, University of Punjab, Punjab, Pakistan *Corresponding author: Muhammad Shakeel, Department of Geography, University of Punjab, Punjab, Pakistan, Tel: 923017002780; E-mail: [email protected] Received date: Sep 08, 2015; Accepted date: Oct 19, 2015; Published date: Oct 21, 2015 Copyright: © 2015 Ali A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

This study was carried out to investigate the spatial patterns of Hepatitis C and its prevalence in males and females in Ghadezai Tehsil District Buner Khyber Paktunkhawa. The patients’ data i.e. residential addresses were taken from the district head quarter Dagger Buner. This data was used for the analysis of the Hepatitis C disease. All the patients’ locations were marked correctly through GPS in the form of x y co-ordinates. These co-ordinates were used to performed spatial analysis, mapping and other quarries of this disease by using GIS software. The results show that the spatial pattern of Hepatitis C in Ghadezai Tehsil was random and uneven. Four areas were identified the hotspots of Hepatitis C in which Dokaddah was in the extreme north Kalakheela in the center while Bazargai and Geraray was in the west of Ghadezai Tehsil. High prevalence of HCV was observed in males (51%) and females (49%) patients. Most number of infections was found in married people (87%) as compared to unmarried people (13%). The age group of 31-45 years was the most affected in the entire study area. Sharing of items among the family members, barbers shops of the area, general practitioners, dental technicians and infected parents were identified the risk factors of HCV in the study area.

Keywords: Hepatitis C; Spatial analysis; GIS; Buner; Khyber clusters and results of point-source studies in proper context [3,6]. paktunkhwa Medical Geography deals the distribution of disease and analysis of geographically indexed health data with respect to demographic, Introduction environmental, behavioral, socioeconomic, genetic, and infectious risk factors [7,8]. In the 19th century the geographers also took interest to The relationship between the disease and location is not a new study systematically the geographic aspects of health and disease. concept if we look in the history of epidemiology since in the ancient Today, with the emerging world-wide occurrence of some infectious Greek era, Hippocrates (5th-4th centuries BC) was aware and diseases the importance of place in understanding health and disease recognized the effect of location on one’s health. Early physicians found seems stronger than ever [9]. that the people living at high and low elevation experienced differences in diseases. The earlier spatial and temporal studies of this virus Spatial patterns indicate where the hot spots of the disease are found suggested that the spread of this virus started in the early twentieth and provide the possibility that whether the disease is related to century and potentially increased a lot up to 1980. According to the specific source are not. Disease maps typically show standardized WHO’s epidemiological data, the prevalence of HCV is less than 1% in mortality or morbidity ratios (SMRs) for geographic areas such as northern Europe, Canada, Australia and USA. While in different countries, counties, or districts. Clusters are also useful to find those regions of Latin America, Central Asia, South East Asia and Africa the areas which require more health facilities as compared to facilities HCV prevalence rate is more than 2% and the prevalence of this already existing. This is helpful for planning in future and policy disease is reported between 5 to 10% [1] The world epidemiological making for disease control. According to an estimate about 130 to 180 data suggested that about 130 to 180 million people that make 2 to 3% million of HCV infections are found presently in the world. The record of the entire world population are victim of HCV and more than 4 of some medical data suggests that HCV spread in a tremendous million people are chronically infected by HCV in Oceania, 16 million manner throughout the world after world war second [10,11]. A in the Arabian countries and Middle East region. The infections are significant diversity in the rate and prevalence of HCV is found in high as 83 million in the continent Asia. The infection caused by HCV different regions of the world. Beside from this great variations occur in Africa is 28 million and America and Europe have 16 and 17.5 in various parts and areas of a country at the same time. In Pakistan million respectively [2,3]. one out of every ten persons is a carrier of hepatitis virus. In Pakistan the knowledge and awareness about the Hepatitis C is very low among Disease maps provide a rapid visual summary of complex the people especially in women due to illiteracy and poverty. In the geographic information’s and may identify delicate patterns in the data study area Buner the high prevalence of HCV is the result of low level that are missed in tabular presentations [4,5]. They are used for of knowledge about this disease, lack of awareness, unhygienic different descriptive purposes, to make hypotheses as to etiology, for conditions, remoteness and the unavailability of quality health surveillance to show areas at high risk, and to aid policy formation and facilities. In this alarming situation it is foremost to make an attempt to resource allocation. They are also useful to help place specific disease examine the spatial pattern of Hepatitis C by using mapping

J Geogr Nat Disast Volume 5 • Issue 3 • 1000146 ISSN:2167-0587 JGND, an open access journal Citation: Ali A, Shakeel M, Khalid S, Ahmed T, Noreen M, et al. (2015) Spatial Patterns of Hepatitis C Disease in Ghadezai Tehsil District Buner, Khyber Paktunkhwa, Pakistan. J Geogr Nat Disast 5: 146. doi:10.4172/2167-0587.1000146

Page 2 of 6 techniques and some statistical methods. The research primarily aimed person of her family. The patient’s locations were captured through to study the distribution, patterns, demographic structure, gender gap GPS in the form of x-y coordinates. As the secondary data lack the and risk factors of Hepatitis C in Upper Buner District [1,12]. proper addresses so the local people of each village were enquired to find out the house of each patient. The coordinate’s data were used for Around 8.6 million Hepatitis C patients are found in the country spatial analysis of the disease and disease mapping. The data of with a 4.8 percent prevalence rate, one out of every ten persons is a registered hepatitis C patients were obtained from the Hepatitis C carrier of hepatitis virus [13]. The area Buner selected for this research Control Cell of District Headquarter Hospital Daggar Buner. This data is due to the high prevalence of Hepatitis C, its remoteness, contains the patient’s names and the relative address. Different GIS unavailability of quality health facilities and existing conditions created techniques were used like spatial analyst tool and Kernel Density by Taliban in which the government and non-governmental agencies analysis was performed to identify the hotspots of the disease. The and organizations cannot work properly to disclose and uncover the Kernel Density calculates the density of features in a neighborhood reality about Hepatitis C disease which is spreading as an epidemic around those features. It can be calculated for both point and line manner in the study area. HCV disease was highest in Punjab (6.7%) features [17-21] (Figure 2). followed by Sindh (5.0%), Balochistan (1.5%) and KPK (1.1 %), [1,14]. In Pakistan one out of every ten persons is a carrier of hepatitis virus. In Pakistan the knowledge and awareness about the Hepatitis C is very low among the people especially in women due to illiteracy and poverty. In the study area Buner the high prevalence of HCV is the result of low level of knowledge about this disease, lack of awareness, unhygienic conditions remoteness and the unavailability of quality health facilities. In this alarming situation it is foremost to make an attempt to examine the spatial pattern of Hepatitis C by using mapping techniques and some statistical methods. The research primarily aimed to study the distribution, patterns, demographic structure, gender gap and risk factors of Hepatitis C in Upper Buner District [9,15,16].

Study Area Buner was a part of district Sawat in the beginning but it has given the status of a separate district in 1991. The total area of Buner is 1865 Sq.Km. Buner lies between 34-9 and 34-43 N latitude and 72-10 and 72-47 E longitude. It is situated at a distance of 120 km from provincial capital Peshawar. Sawat district lie in the north, Malakand in the North West Mardan in the west, Sawabi in the south and river Indust in the east of Buner district. District Buner is divided in different tehsils like Daggar, Gadezai, Chagharzai, Totalye, Chamla and Gagra. There are total 27 union councils. The population of Buner is 506048 (1998 Census).The males and females ratio is exactly equal i.e 50% males and 50% females with an average annual growth of 3.9%, having a population density of 271 persons/ Sq.Km. Muslims are 95% of the Figure 1: The location of the study area. total population while the remaining 5% are Sikhs and Hindus minorities. Dagger is the district headquarter and main administrative town of Buner [1,14] (Figure 1). Results and Discussions Methodology The total number of patients in the study area was 844; these The research was based on primary as well as the secondary data. patients are found in 29 different villages fall in two tehsils Dagger and The primary data was collected directly from the patients through Ghdeyzai tehsil. The residential addresses of all these patients were structured questionnaire, while the secondary data was obtained from taken from the district head quarter Dagger Buner (Table 1). the Hepatitis C Control Cell of District Headquarter Hospital Daggar The Figure 3 shows the prevalence of Hepatitis C disease in various Buner, Khyber Pakhtunkhwa for the period of three years 2011 to villages of Ghadezai Tehsil. In some villages like in Nansir, Bahiaikalay, 2014. The research was conducted in the Buner District of Khyber Leganay, Ghazikhanay and Sultanwas has high prevalence of Hepatitis Pakhtun Khwa. Ghadezai Tehsil of Upper Buner was taken as the study C in Males. While villages like Narbatawal, Peerbaba, Geraray, Jowar area. A survey of 21 villages was performed in which the Hepatitis C and Katkala has more Hepatitis C cases in males than females. The patients were found. prevalence of HCV disease in females are more in the villages like The field survey was conducted and the data were collected through Bazargai, Bampoha, Geraray etc of Salarzai tribe because the females of structured questionnaires. A total number of 254 questionnaires were these villages are more exposes to the risk factors as they are working filled and the data from 160 males and 94 female respondents were not only in the houses but also in the agriculture fields. They also bring collected. The questions were translated into Pashto language. From fodder for animals from the nearby hills. The role of the females in males and old women the questionnaires were filled directly while these villages is very active in indoor and outdoor activities as compare from young females the indirect method was used through a third to the males. While in villages like Peer baba, Pacha kalay and Bhai

Page 3 of 6 kalay etc. males are more affected because in these villages the men families are the causes of vertical and horizontal transmission of this have active role in the society. In Ghadezai tehsil both the males and disease. females are highly affected and are at high risk to this disease. The high illiteracy rate and low level of awareness about this disease in the people of this area are the important factors behind the prevailing situation.

Name of the village Male Female Married Unmarried

Jowar 13 19 26 6

Bazargai 46 47 78 15

Geraray 24 34 52 6

Bampoha 22 22 40 4

Leganay 8 3 10 1

Kinger gali 10 8 16 2 Figure 2: Comparative Analysis of the Hepatitis C Patients in Nansir 9 2 10 1 Ghadezai Tehsil.

Kohi 6 7 12 1

Charay 7 8 13 2

Katkala 5 12 16 1

Char 6 3 9 0

Shoprang 3 3 5 1

Salarzomira 5 6 10 1

Kalakheela 21 27 40 8

BhaiKalay 22 10 27 5

Pachakalay 12 10 18 4

Sultanwas 6 3 8 1

Dokaddah 62 53 99 16

Pir baba 4 7 9 2

Batay 11 5 13 3 Figure 3: Distributions of Patients in terms of Gender.

Narbatawal 2 10 10 2

Ghazikhanay 16 7 20 3

Table 1: Hepatitis C Patients detail in the study Area. Source: District Headquarter Hospital Daggar Buner, 2014.

The Figure 4 shows the affected age groups of Hepatitis C patients Ghadezai tehsil. The most affected age group is 31-45. The age group 46-60 is second most affected. The group 16-30 is moderately and other is less affected. This is clear from the graph that mostly young and mature people are the victim of this disease while children and old Figure 4: Hepatitis C Patients by Age in Ghadezai Tehsil. persons are safe. Both the mature and young people are working groups and are more exposed to their life activities and risk factors in different places like in houses, bazar, play grounds, work places and In all the villages of Ghadezai Tehsil the HCV cases were mostly other gathering places etc. The low level of awareness of this disease in found in married people than in unmarried people as shown in Figures the people of this area is main cause of spreading of this disease. The 5 and 6. Over 80% married people were the victim of this disease in young and mature males mostly prefer shave in barber shops than at each village. Some villages like Bampoha (91%), Dokaddah (87%), home which is one of the important reason of this disease in these two Ghazikhanay (86%), Kalakheela (83%), Bazargai (83%) and Pachakalay age groups. The join family system of the area and marriages in its own (82%) etc. have high proportion of married HCV patients. The reason

Page 4 of 6 is that the married people are at more risks like infected life partner Geraray and Bampoha having 93, 58 and 44 cases respectively and are and their exposure to a variety of life activities due to greater in the northwest of Ghadezai tehsil (Figures 7 and 8). responsibilities. The tradition of early marriages in their own families is also one of the important factors of high prevalence of HCV in married people of this area.

Figure 5: Village base HCV prevalence in terms of Marital Status in Ghadezai Tehsil.

Figure 7: Hotspots of Hepatitis C Disease in the Study Area.

Figure 6: Distribution of Hepatitis C Patients in terms of Marital Status.

Figure 8: High incidence areas of Hepatitis C in Upper Buner. Hot spot are those areas where the presence of affected patients is high than average and high from rest of the area. The cases in the hotspots like in Dokaddah, Bazargai, Geraray, Torwasak, Anghapur, Kalakheela, Shanay and Bampoha are in cluster manner. The cases in Risk factors of Hepatitis C in the study area these villages are found closely with each other and mostly Four significant factors were observed in our study that responsible concentrated in the center or the core area of the villages. While in in the transmission of Hepatitis C disease in the upper Buner. These other villages the cases are found in random and scattered manner. In factors are as under. small villages like Kingergali, Nansir, Leganay, Charay, Char, Salarzomaira, Ashezomaira, Newaykalay, Elay, sultanwas, Sharing of items: About 60% patients share items like needle, Ghazikhanay, Batay, Narbatawal and Pacha kalay the distribution of Meswak, Dandasa (the bark of wall nut use by local people for cleaning HCV cases are random and scattered. In large villages the houses are teeth), and tooth brush. Sharing of items is one of the reasons of wall to wall attached and this is why the cases are found closely with Hepatitis C disease in the area. They not only share items of daily use each other. Over all eight villages are found the hot spots of hepatitis c with the family members but also the neighbors as well. The sharing of in the entire study area. These hot spots are Dokaddah, Bazargai, the needle is almost very common during the piercing of ears and nose Geraray, Torwasak, Anghapur, Kalakheela, Shanay and Bampoha. The within the family members especially the females. The same thing spatial distributions of these hot spots are as Dokaddah and Kalakheela happen when the needle is used to come out the sticking spike from having 115 and 48 cases respectively in the north east, Bazargai, the body. They share these items due to unawareness and low level of education.

Page 5 of 6

Barbers shops: Among the participants 78% make their shaves at close to each other and mostly in single house three to five cases were barber shops. It means that they are involved in the spreading of this found. Kalkheela village have total of 48 cases in which43% males and disease. In these shops mostly the people are at high risk in the sense 57% females patients. The cases here mostly concentrated in the central that at rush time the barbers not change the used water of the first part of the village and also in close proximity. As a whole in Ghadezai shave and use it for the next one and the use of Phtkari (Alum) piece as tehsil males (51%) are more victim of this disease than females (49%). a common antiseptic material during cut. Beside from this they used a The age group 31-45 was much highly affected. The high prevalence of common razor for armpit shave. Hepatitis C in both the genders is the result of the careless attitude and unawareness of this disease among the people of this tehsil. General practitioners clinics: When the patients inquired about the choice of doctor for treatment during illness 85% of patients go to General practitioners for treatment during illness. These practitioners References reuse the syringe especially at evening and night time when the 1. Umar M, Bushra H, Ahmad M (2010) Hepatitis C in Pakistan: A Review disposable syringe are used and nothing remain. The same thing of Available Data. International Montly. Journal in the Field of happened during the rush time as well. The dental instruments are not Hepatology 10: 205–214. sterilized properly by the dental technicians. These instruments are 2. Lavanchy D (2011) Evolving epidemiology of hepatitis C virus. Clinical only put in boil water for an hour or two hours and then dried it with Microbiology and Infection 17: 107-115. cotton or cloth and reused. Besides from ignorance and unawareness 3. Harris R, Hope D, Morongiu A, Hickman M, Ncube F (2012) Spatial the technicians do so to save time and money. mapping of hepatitis C prevalence in recent injecting drug users in contact with services. Epidemiol Infect 140: 1054-1063. Hepatitis C positive life partner: The present study shows that 17% 4. Kauhl B, Heil J, Hoebe CJ, Schweikart J, Krafft T, et al. (2015) The Spatial of the patients has their positive Hepatitis C life partners. The role of Distribution of Hepatitis C Virus Infections and Associated this mode of transmission is also very significant. Because the infection Determinants-An Application of a Geographically Weighted Poisson can directly transmits from the infected to the healthy life partner and Regression for Evidence-Based Screening Interventions in Hotspots. indirectly into their babies through vertical transmission. This is why PLoS One, 10: e0135656. this mode of transmission is also one of the major risk factor of high 5. Hu T, Du Q, Ren F, Liang S, Lin D (2014) Spatial analysis of the home prevalence of HCV in the area. addresses of hospital patients with hepatitis B infection or hepatoma in Shenzhen, China from 2010 to 2012. Int J Environ Res Public Health 11: 3143-3155. Conclusion 6. Terran A (2010) A Geographical Examination of Social, Behavioral, and HCV is one of the major health problems throughout the world. Demographic Determinants Association with Hepatitis C Viral Infection in the State of Georgia. B.A, University of Michigan, Atlanta. However the prevalence rate of this disease varies from region to Elliott WD (2004) Spatial Epidemiology: Current Approaches and Future region and from country to country. In these 844 patients 435 were 7. Challenges. Environ Health Perspect 9: 998-1006. males and 409 female patients. Most number of the patients were 8. Arden WB (2008) Medical Geography in Public Health and Tropical married i.e. 731 and 113 were unmarried. Our study revealed that Medicine: Case Studies from Brazil. The Department of Geography and Ghadezai tehsil is the most affected tehsil in the area, in which total of Anthropology, Louisiana State University, Louisiana. 626 cases were found in which 320 were male and 306 were female 9. Aziz S, Ngui R, Lim YAL, Sholehah I, Nur Farhana J (2012) Spatial patients. The married were 542 and unmarried patients were only 84. pattern of 2009 dengue distribution in Kuala Lumpur using GIS The large number of cases in this area is due to low level of education application. Tropical Biomedicine 29: 113-120. and awareness among the people. In all the villages of this tehsil the 10. Mujeeb A, Shahabb SS, Hyderc AA (2000) Geographical Display of HCV cases were found in which some villages like Bazargai, Geraray Health Information: Study of Hepatitis C Infection in Karachi, Pakistan. and Bampoha villages were quite notable. Among these three villages Public Health 114: 413-415. Bazargai village has 93 cases and most severely affected. It is noted that 11. Ahmad N, Asgher M, Shafique M, Qureshi AJ (2007) An evidence of high the join family system and marriages in its own families are their prevalence of Hepatitis C virus in Faisalabad, Pakistan. Saudi Med J 28: causes. The threat of infection to healthy persons can be reduced by 390-395. conducting test of both the life partner before marriage and not 12. Jamil SM, Ali H, Shaheen R, Basit A (2010) Prevalence, Knowledge and Awareness of Hepatitis C Among Residents of Three Union Councils in sharing the items like needle, meswak, dandasa, and tooth brush Mansehra. J Ayub Med Coll Abbottabad 22: 192-196. among the family members. In Geraray total numbers of cases were 58 13. WHO (2012) World Health Statistics, Geneva: Hepatitis C. in which 41% males and 59% females were infected by HCV. In Bampoha village 44 cases were founded here the ratio of males and 14. Anwar Z, Hussain S, Ahamad FS, Khan AA, Jamil T (2012) Prevalence of Hepatitis B detected through RT PCR in Khyber Pakhtunkhwa. African females was 50% each. Over all the gender analysis of Ghadezai tehsil Journal of Microbiology Research 6: 3631-3634. shows that males (51%) are more affected than females (49%). But 15. Bari A, Akhtar S, Mohammad H, Stephen P (2001) Risk Factors for greater numbers of infections in females (49%) of this tehsil are due to Hepatitis C Virus Infection in Male Adults in Rawalpindi–Islamabad, their low level of education and awareness of this disease. They are Pakistan. A Europaen journal of TM&IH 6: 732-738. exposed to a variety of risk factors at different places, as they play a 16. Ali M, Idrees M, Ali L, Hussain A, Rehman I (2011) Hepatitis B virus in vital role not only inside their houses but also working in the fields Pakistan: A systematic review of prevalence, risk factors, awareness status bring drinking water and fodder for the animals from the nearby hills. and genotypes. Virology Journal 8: 1-9. Most numbers of cases were found in married people (87%) of this 17. ESRI (2014) ArcGIS 10. tehsil. While two age groups .i.e. 31-45 and 46-60 were the most 18. Boodram B, Elizabeth T, Lawrence J (2010) Socio-Behavioral and affected in all the villages of Ghadezai tehsil. High frequency of Geographic Correlates of Prevalent Hepatitis C Virus Infection among patients was found in the age group 31-45. Dokaddah is the severely Young Injection Drug Users in Metropolitan Baltimore and Chicago. affected village in the entire study area where 115 patients was found in Division of Epidemiology and Biostatistics 111: 136-145. which 53% males and 47% females’ patients. The cases here were very

Page 6 of 6

19. Bosan A, Qureshi H, Bile KM, Ahmad I, Hafiz R (2010) A review of 21. Carl L, Cui Y, Aylur KS, Suniti S, Mehta SH (2011) The relationship hepatitis viral infections in Pakistan. National Institute of Health 60: between social network factors, HIV, and Hepatitis C among injection 1045-1058. drug users in Chennai, India. Drug and Alcohol Dependence 117: 50-54. 20. Campiotto S, Pinho JRR, Carrilho FJ, Da Silva LC, Souto FJD (2005) Geographic distribution of hepatitis C virus genotypes in Brazil. Braz J Med Biol Res 38: 41-49.

J Geogr Nat Disast Volume 5 • Issue 3 • 1000146 ISSN:2167-0587 JGND, an open access journal